Editing Photoplethysmogram

{{Short description|Chart of tissue blood volume changes}}
{{more citations needed|date=March 2019}}

{{Infobox diagnostic
| Name            = Photoplethysmography
| Image           = Image:PPG.PNG|thumb|
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| Caption         = Representative PPG taken from an ear pulse oximeter. Variation in amplitude are from Respiratory Induced Variation.
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| MeshID          = D017156
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A '''photoplethysmogram''' ('''PPG''') is an optically obtained [[plethysmograph|plethysmogram]] that can be used to detect blood volume changes in the microvascular bed of tissue.<ref name= Allen>{{cite journal | vauthors = Allen J | title = Photoplethysmography and its application in clinical physiological measurement | journal = Physiological Measurement | volume = 28 | issue = 3 | pages = R1–39 | date = March 2007 | pmid = 17322588 | doi = 10.1088/0967-3334/28/3/R01 | s2cid = 11450080 | url = }}</ref><ref name=Kyriacou>{{cite book | veditors = Kyriacou PA, Allen J | title = Photoplethysmography: Technology, Signal Analysis and Applications | publisher = Elsevier | date = 2021 }}</ref> A PPG is often obtained by using a [[pulse oximeter]] which illuminates the [[skin]] and measures changes in light absorption.<ref name=Shelley>{{cite book | vauthors = Shelley K, Shelley S, Lake C | chapter = Pulse Oximeter Waveform: Photoelectric Plethysmography | title = Clinical Monitoring | veditors = Lake C, Hines R, Blitt C | publisher = W.B. Saunders Company | date = 2001 | pages = 420–428 }}</ref> A conventional pulse oximeter monitors the perfusion of blood to the dermis and subcutaneous tissue of the skin.  [[Image:Pulse oximiter, Photoplethysmograph.jpg|thumb|right|250px|Finger pulse oximeter]]

With each [[cardiac cycle]] the heart pumps blood to the periphery. Even though this pressure pulse is somewhat damped by the time it reaches the skin, it is enough to distend the arteries and arterioles in the subcutaneous tissue. If the pulse oximeter is attached without compressing the skin, a pressure pulse can also be seen from the venous plexus, as a small secondary peak.

The change in volume caused by the pressure pulse is detected by illuminating the skin with the light from a [[light-emitting diode]] (LED) and then measuring the amount of light either transmitted or reflected to a photodiode.<ref name=Aguilar>{{Cite book|doi = 10.1109/IEMBS.2007.4352784|chapter = LED power reduction trade-offs for ambulatory pulse oximetry|title = 2007 29th Annual International Conference of the IEEE Engineering in Medicine and Biology Society|year = 2007| vauthors = Pelaez EA, Villegas ER |volume = 2007|pages = 2296–2299|pmid = 18002450|isbn = 978-1-4244-0787-3|s2cid = 34626885}}</ref> Each cardiac cycle appears as a peak, as seen in the figure. Because blood flow to the skin can be modulated by multiple other physiological systems, the PPG can also be used to monitor breathing, [[hypovolemia]], and other circulatory conditions.<ref>{{cite journal | vauthors = Reisner A, Shaltis PA, McCombie D, Asada HH | title = Utility of the photoplethysmogram in circulatory monitoring | journal = Anesthesiology | volume = 108 | issue = 5 | pages = 950–958 | date = May 2008 | pmid = 18431132 | doi = 10.1097/ALN.0b013e31816c89e1 | doi-access = free }}</ref> Additionally, the shape of the PPG waveform differs from subject to subject, and varies with the location and manner in which the pulse oximeter is attached.

Although PPG sensors are in common use in a number of commercial and clinical applications, the exact mechanisms determining the shape of the PPG waveform are not yet fully understood.<ref name="Charlton-2022">{{cite journal | vauthors = Charlton PH, Kyriaco PA, Mant J, Marozas V, Chowienczyk P, Alastruey J | title = Wearable Photoplethysmography for Cardiovascular Monitoring | journal = Proceedings of the IEEE. Institute of Electrical and Electronics Engineers | volume = 110 | issue = 3 | pages = 355–381 | date = March 2022 | pmid = 35356509 | pmc = 7612541 | doi = 10.1109/JPROC.2022.3149785 }}</ref>

== Sites for measuring PPG ==
While [[pulse oximeter]]s are commonly used [[Medical devices|medical device]]s, the PPG signal they record is rarely displayed and is nominally only processed to determine [[Pulse oximetry|blood oxygenation]] and [[Heart rate monitor|heart rate]].<ref name="Kyriacou" /> The PPG can be obtained from transmissive absorption (as at the finger tip) or reflection (as on the forehead).<ref name="Kyriacou" />

In outpatient settings, pulse oximeters are commonly worn on the finger.  However, in cases of shock, [[hypothermia]], etc., blood flow to the periphery can be reduced, resulting in a PPG without a discernible cardiac pulse.<ref>{{cite book |doi=10.1109/EMBC.2015.7320237 |pmid=26738137 |isbn=978-1-4244-9271-8 |s2cid=4574235 |chapter-url=http://openaccess.city.ac.uk/13277/1/IEEE%20EMBC%202015%20Karthik%201.pdf |chapter=Investigation of photoplethysmography and arterial blood oxygen saturation from the ear-canal and the finger under conditions of artificially induced hypothermia |title=2015 37th Annual International Conference of the IEEE Engineering in Medicine and Biology Society (EMBC) |year=2015 | vauthors = Budidha K, Kyriacou PA |journal=<!-- --> |volume=2015 |pages=7954–7957 }}</ref>  In this case, a PPG can be obtained from a pulse oximeter on the head, with the most common sites being the ear, [[nasal septum]], and forehead. PPG can also be configured for multi-site photoplethysmography (MPPG), e.g. by making simultaneous measurements from the right and left ear lobes, index fingers and great toes, and offering further opportunities for the assessment of patients with suspected peripheral arterial disease, autonomic dysfunction, endothelial dysfunction, and arterial stiffness. MPPG also offers significant potential for data mining, e.g. using deep learning, as well as a range of other innovative pulse wave analysis techniques.<ref>{{cite journal | vauthors = Allen J, Overbeck K, Nath AF, Murray A, Stansby G | title = A prospective comparison of bilateral photoplethysmography versus the ankle-brachial pressure index for detecting and quantifying lower limb peripheral arterial disease | journal = Journal of Vascular Surgery | volume = 47 | issue = 4 | pages = 794–802 | date = April 2008 | pmid = 18381141 | doi = 10.1016/j.jvs.2007.11.057 | doi-access = free }}</ref><ref>{{cite journal | vauthors = McKay ND, Griffiths B, Di Maria C, Hedley S, Murray A, Allen J | title = Novel photoplethysmography cardiovascular assessments in patients with Raynaud's phenomenon and systemic sclerosis: a pilot study | journal = Rheumatology | volume = 53 | issue = 10 | pages = 1855–1863 | date = October 2014 | pmid = 24850874 | doi = 10.1093/rheumatology/keu196 | doi-access =  }}</ref><ref>{{cite journal | vauthors = Mizeva I, Di Maria C, Frick P, Podtaev S, Allen J | title = Quantifying the correlation between photoplethysmography and laser Doppler flowmetry microvascular low-frequency oscillations | journal = Journal of Biomedical Optics | volume = 20 | issue = 3 | pages = 037007 | date = March 2015 | pmid = 25764202 | doi = 10.1117/1.JBO.20.3.037007 | s2cid = 206437523 | bibcode = 2015JBO....20c7007M | doi-access = free }}</ref><ref name="Abdulrhman H 2020">{{Cite journal| vauthors = Al-Jebrni AH, Chwyl B, Wang XY, Wong A, Saab BJ |date=2020-05-01|title=AI-enabled remote and objective quantification of stress at scale|journal=Biomedical Signal Processing and Control|language=en|volume=59|pages=101929|doi=10.1016/j.bspc.2020.101929|issn=1746-8094|doi-access=free}}</ref>

Motion artifacts are often a limiting factor preventing accurate readings during exercise and free living conditions.<ref name="Charlton-2022" />

== Uses ==
===Monitoring heart rate and cardiac cycle===
[[Image:PVC detectionUsing PGG.png|thumb|left|300px|Premature Ventricular Contraction (PVC) can be seen in the PPG just as in the EKG and the Blood Pressure (BP).]]
[[Image:VenousPulsationAnd PGG.png|thumb|right|300px|Venous pulsations can clearly be seen in this PPG.]]

Because the skin is so richly perfused, it is relatively easy to detect the pulsatile component of the cardiac cycle. The DC component of the signal is attributable to the bulk absorption of the skin tissue, while the AC component is directly attributable to variation in blood volume in the skin caused by the pressure pulse of the cardiac cycle.

The height of AC component of the photoplethysmogram is proportional to the pulse pressure, the difference between the systolic and diastolic pressure in the arteries. As seen in the figure showing [[premature ventricular contraction]]s (PVCs), the PPG pulse for the cardiac cycle with the PVC results in lower amplitude [[blood pressure]] and a PPG. [[Ventricular tachycardia]] and [[ventricular fibrillation]] can also be detected.<ref name="pmid25480769">{{cite journal | vauthors = Alian AA, Shelley KH | title = Photoplethysmography | journal = Best Practice & Research. Clinical Anaesthesiology | volume = 28 | issue = 4 | pages = 395–406 | date = December 2014 | pmid = 25480769 | doi = 10.1016/j.bpa.2014.08.006 }}</ref>

===Monitoring respiration===
[[Image:NiprideEffectOnPPG-large.png|thumb|left|300px|The effects of [[sodium nitroprusside]] (Nipride), a peripheral vasodilator, on the finger PPG of a sedated subject. As expected, the PPG amplitude increases after infusion, and additionally, the Respiratory Induced Variation (RIV) becomes enhanced.<ref name=pmid18048895/>]]

Respiration affects the cardiac cycle by varying the intrapleural pressure, the pressure between the thoracic wall and the lungs. Since the heart resides in the thoracic cavity between the lungs, the partial pressure of inhaling and exhaling greatly influence the pressure on the vena cava and the filling of the right atrium.

During inspiration, intrapleural pressure decreases by up to 4&nbsp;mm Hg, which distends the right atrium, allowing for faster filling from the vena cava, increasing ventricular preload, but decreasing stroke volume. Conversely during expiration, the heart is compressed, decreasing cardiac efficiency and increasing stroke volume. When the frequency and depth of respiration increases, the venous return increases, leading to increased cardiac output.<ref>{{cite journal | vauthors = Shelley KH, Jablonka DH, Awad AA, Stout RG, Rezkanna H, Silverman DG | title = What is the best site for measuring the effect of ventilation on the pulse oximeter waveform? | journal = Anesthesia and Analgesia | volume = 103 | issue = 2 | pages = 372–7, table of contents | date = August 2006 | pmid = 16861419 | doi = 10.1213/01.ane.0000222477.67637.17 | s2cid = 6926327 | doi-access = free }}</ref>

Much research has focused on estimating [[respiratory rate]] from the photoplethysmogram,<ref>{{cite journal | vauthors = Charlton PH, Birrenkott DA, Bonnici T, Pimentel MA, Johnson AE, Alastruey J, Tarassenko L, Watkinson PJ, Beale R, Clifton DA | display-authors = 6 | title = Breathing Rate Estimation From the Electrocardiogram and Photoplethysmogram: A Review | journal = IEEE Reviews in Biomedical Engineering | volume = 11 | pages = 2–20 | date = 2018 | pmid = 29990026 | pmc = 7612521 | doi = 10.1109/RBME.2017.2763681 }}</ref> as well as more detailed respiratory measurements such as inspiratory time.<ref>{{cite journal | vauthors = Davies HJ, Bachtiger P, Williams I, Molyneaux PL, Peters NS, Mandic DP | title = Wearable In-Ear PPG: Detailed Respiratory Variations Enable Classification of COPD | journal = IEEE Transactions on Bio-Medical Engineering | volume = 69 | issue = 7 | pages = 2390–2400 | date = July 2022 | pmid = 35077352 | doi = 10.1109/TBME.2022.3145688 | hdl = 10044/1/96220 | s2cid = 246287257 | hdl-access = free }}</ref>

===Monitoring depth of anesthesia===
[[Image:EffectsOfIncisionOnPPG-Large.png|thumb|right|300px|Effects of an incision on a subject under general anesthesia on the photoplethysmograph (PPG) and blood pressure (BP).]]

Anesthesiologists must often judge subjectively whether a patient is sufficiently anesthetized for surgery. As seen in the figure, if a patient is not sufficiently anesthetized, the sympathetic nervous system response to an incision can generate an immediate response in the amplitude of the PPG.<ref name=pmid18048895>{{cite journal | vauthors = Shelley KH | title = Photoplethysmography: beyond the calculation of arterial oxygen saturation and heart rate | journal = Anesthesia and Analgesia | volume = 105 | issue = 6 Suppl | pages = S31–S36 | date = December 2007 | pmid = 18048895 | doi = 10.1213/01.ane.0000269512.82836.c9 | s2cid = 21556782 | doi-access = free }}</ref>

===Monitoring hypo- and hypervolemia===
Shamir, Eidelman, et al. studied the interaction between inspiration and removal of 10% of a patient’s blood volume for blood banking before surgery.<ref name="pmid10364990">{{cite journal | vauthors = Shamir M, Eidelman LA, Floman Y, Kaplan L, Pizov R | title = Pulse oximetry plethysmographic waveform during changes in blood volume | journal = British Journal of Anaesthesia | volume = 82 | issue = 2 | pages = 178–81 | date = February 1999 | pmid = 10364990 | doi = 10.1093/bja/82.2.178 | doi-access = free }}</ref> They found that blood loss could be detected both from the photoplethysmogram from a pulse oximeter and an arterial catheter. Patients showed a decrease in the cardiac pulse amplitude caused by reduced cardiac preload during exhalation when the heart is being compressed.

===Monitoring blood pressure===
The [[FDA]] reportedly provided clearance to a photoplethysmography-based cuffless blood pressure monitor in August 2019.<ref>{{cite web |url= https://www.medscape.com/viewarticle/917375 |title= FDA Okays Biobeat's Cuffless Blood Pressure Monitor | vauthors = Wendling P |date= 28 August 2019 |publisher= Medscape|access-date= 5 September 2019}}</ref>

== Remote photoplethysmography ==

===Conventional imaging===
While photoplethysmography commonly requires some form of contact with the human skin (e.g., ear, finger), remote photoplethysmography allows  physiological processes such as blood flow to be determined without skin contact. This is achieved by using face video to analyze subtle momentary changes in the subject's skin color which are not detectable to the human eye.<ref>{{cite journal | vauthors = Verkruysse W, Svaasand LO, Nelson JS | title = Remote plethysmographic imaging using ambient light | journal = Optics Express | volume = 16 | issue = 26 | pages = 21434–21445 | date = December 2008 | pmid = 19104573 | pmc = 2717852 | doi = 10.1364/OE.16.021434 | bibcode = 2008OExpr..1621434V }}</ref><ref>{{cite journal | vauthors = Rouast PV, Adam MT, Chiong R, Cornforth D, Lux E |title = Remote heart rate measurement using low-cost RGB face video: A technical literature review |journal = Frontiers of Computer Science |volume = 12 | pages = 858–872 |year = 2018 |issue = 5 |doi = 10.1007/s11704-016-6243-6|s2cid=1483621 }}</ref> Such camera-based measurement of blood [[oxygen saturation|oxygen levels]] provides a contactless alternative to conventional photoplethysmography. For instance, it can be used to monitor the heart rate of newborn babies,<ref>{{cite AV media |url-status = live |archive-url = https://ghostarchive.org/varchive/youtube/20211211/7Nq73-jYbpY |archive-date = 2021-12-11| url = https://www.youtube.com/watch?v=7Nq73-jYbpY |title = Example of contactless monitoring in action |website=[[YouTube]]}}{{cbignore}}</ref>  or analyzed with deep neural networks to quantify stress levels.<ref name="Abdulrhman H 2020"/>

===Digital holography===
[[File:Final 5dff67f59d8d9300145440a4 3.gif|thumb|left|350px|Photoplethysmography of the thumb by off-axis digital holography.]]
[[File:Final 5ddec7a2afcb84001426276a 982750.gif|thumb|right|300px|pulsatile waves on the back of a frog measured by off-axis holographic photoplethysmography]]

Remote photoplethysmography can also be performed by [[digital holography]], which is sensitive to the phase of light waves, and hence can reveal sub-micron out-of-plane motion. In particular, wide-field imaging of pulsatile motion induced by blood flow can be measured on the thumb by [[digital holography]]. The results are comparable to blood pulse monitored by plethysmography during an occlusion-reperfusion experiment.<ref>{{cite journal | vauthors = Bencteux J, Pagnoux P, Kostas T, Bayat S, Atlan M | title = Holographic laser Doppler imaging of pulsatile blood flow | journal = Journal of Biomedical Optics | volume = 20 | issue = 6 | pages = 066006 | date = June 2015 | pmid = 26085180 | doi = 10.1117/1.JBO.20.6.066006 | arxiv = 1501.05776 | s2cid = 20234484 | bibcode = 2015JBO....20f6006B }}</ref> A major advantage of this system is that no physical contact with the studied tissue surface area is required. The two major limitations of this approach are (i) the off-axis interferometric configuration that reduces the available spatial bandwidth of the [[sensor array]], and (ii) the use of [[short-time Fourier transform]] (via [[discrete Fourier transform]]) analysis that filters-off physiological signals.

[[File:Hand Emmanuel gain6 color 9 35.gif|thumb|right|300px|laser Doppler imaging of pulse waves on the surface of the hand by holographic photoplethysmography from on-axis digital interferometry.]]
[[Principal component analysis]] of digital holograms <ref>{{cite arXiv |eprint = 2004.00923| vauthors = Puyo L, Bellonnet-Mottet L, Martin A, Te F, Paques M, Atlan M |title = Real-time digital holography of the retina by principal component analysis|year = 2020|class = physics.med-ph}}</ref> reconstructed from digitized interferograms acquired at rates beyond ~1000 frames per second reveals surface waves on the hand. This method is an efficient way of performing digital holography from on-axis interferograms, which alleviates both the spatial bandwidth reduction of the off-axis configuration and the filtering of physiological signals. A higher spatial bandwidth is crucial for larger image field of view.

A refinement of holographic photoplethysmography, holographic [[laser Doppler imaging]], enables non-invasive blood flow pulse wave monitoring in blood vessels of the [[retina]], [[choroid]], [[conjunctiva]], and [[iris (anatomy)|iris]].<ref>{{cite journal | vauthors = Puyo L, Paques M, Fink M, Sahel JA, Atlan M | title = ''In vivo'' laser Doppler holography of the human retina | journal = Biomedical Optics Express | volume = 9 | issue = 9 | pages = 4113–4129 | date = September 2018 | pmid = 30615709 | pmc = 6157768 | doi = 10.1364/BOE.9.004113 | arxiv = 1804.10066 }}</ref>
In particular, laser Doppler holography of the eye fundus, the choroid constitutes the predominant contribution to the high frequency laser Doppler signal. It is however possible to circumvent its influence by subtracting the spatially averaged baseline signal, and achieve high temporal resolution and full-field imaging capability of pulsatile blood flow.

== See also ==
* [[Clitoral photoplethysmograph]]
* [[Heart rate monitor]]
* [[Hemodynamics]]
* [[Laser Doppler imaging]]
* [[Plethysmograph]]
* {{Section link|Pulse oximetry|Derived measurements}}
* [[Vaginal photoplethysmograph]]

== References ==
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[[Category:Biofeedback]]
[[Category:Medical monitoring]]
[[Category:Vascular procedures]]